Hospital stays get riskier in the night

By SANDRA G. BOODMAN The Washington Post

Thursday

Jun 9, 2011 at 12:01 AM

Being in a hospital at night or over a weekend can be hazardous to your health, and even has a name: "the weekend effect." A raft of studies have documented higher rates of death, complications and medical errors affecting patients treated at night or on weekends.

"After normal working hours it's mostly maintenance," said Jessie Gruman, 56, director of the Washington-based Center for Advancing Health, a nonprofit health policy group. "There's a real sense of vulnerability you have at night when you know things are not happening at full speed. There's less nursing care, less access to a doctor and more demands on doctors," added Gruman, a veteran of more than 35 years of hospitalizations to treat cancer-related illnesses.

To bridge the chasm between the day and night shifts, hospitals from Syracuse to Seattle are hiring a new breed of subspecialist called a "nocturnist."

A notcturnist is an experienced doctor who works overnight taking care of patients outside the emergency room.

The growing demand for these physicians, who typically work fewer hours and command higher salaries than their daytime counterparts, is being fueled by several factors: the widespread acceptance of inpatient specialists known as hospitalists, who are often eager to bolster night coverage by hiring nocturnists; mandatory limits on the work hours of interns and residents, the most inexperienced doctors who traditionally cared for patients at night in teaching hospitals with little supervision; and a push by the federal government and other groups to improve safety.

"I think it's a very good thing for patients," said John Nelson, a pioneer of the hospitalist movement who coined the term "nocturnist."

Added Nelson, who is based in Seattle: "It shouldn't matter if a patient arrives with pneumonia at noon or midnight. What matters is that patients have a doctor who's there and awake and expecting to work."

That may not be the case. A 2008 study published in the Journal of the American Medical Association found that patients who suffered a heart attack in the hospital during off hours -- when 50 to 70 percent of patients are admitted -- were less likely to survive than those who had a cardiac arrest during normal business hours.

Last year researchers at the University of Pennsylvania found that the quality of cardiopulmonary resuscitation at three urban teaching hospitals was poorer at night than it was during the day. And the president of New York's Beth Israel Medical Center decried the "stark discrepancy in quality between daytime and nighttime inpatient services" in a 2008 article in the New England Journal of Medicine.

Linda Dembo knows firsthand what can happen to hospital patients at night. In May 2007, her 13-year-old son Jonathan was admitted to a St. Louis hospital for surgery to fix a blocked shunt that had been implanted in his head as part of successful treatment for brain cancer he had as a baby.

The neurosurgeon was at home, and Jonathan was being cared for by a resident, his mother said.

"It was a skeleton staff and very quiet," said Dembo, recalling that Sunday night. She said she insisted that a nurse summon a doctor when her son began complaining of a severe headache around 9 p.m. Dembo said that the resident on duty ordered a sedative by phone; she and her son fell asleep around 10:30, and Dembo said that records show no doctor saw him.

At 5 a.m., Jonathan was found dead; an autopsy was not performed, but Dembo said she was told that he probably died of aspiration, essentially choking in his sleep.

"I know in my heart that had a doctor come and seen him, the outcome would have been very different," she said.

Catherine Washburn, a nocturnist at Johns Hopkins Bayview Medical Center, said that adding physicians at night benefits patients because they can start treatment immediately. "I can grease the wheels ... and move people into the hospital more quickly and efficiently," she said.

Patients bound for the intensive care unit who once waited for as long as six hours in the emergency room to claim a bed are now moved into the intensive care unit within 90 minutes of arrival.

Precise numbers are not available, but Nelson estimates that about 1,500 hospitals employ at least one nocturnist, compared with fewer than 100 a decade ago.

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